BACKGROUND: Robotic assisted radical prostatectomy (RARP) is gaining widespread acceptance as a minimally invasive treatment option for prostate cancer. The transperitoneal (TP) approach the most widely used. While we prefer the extraperitoneal approach (EP), our own impression and commonly held belief is that EP prolongs access and setup times. We compared our initial experience with both TP and EP approaches to RARP, with particular focus on operative parameters.
METHODS: Between October 2006 and April 2007 66 consecutive EP and 25 TP RARP were performed by a single surgeon (IT) at the Lahey Clinic Medical Center. The approach was tailored to each patient in a nonrandomized fashion based on body habitus and prior surgery. Charts were reviewed retrospectively for demographical information, operative data and postoperative complications. The following time points were recorded prospectively: patient positioning, port placement and docking, endopelvic dissection, dorsal vein ligation, bladder neck dissection, seminal vesicle dissection, neurovascular bundle dissection, anastomosis, specimen removal and closure. These were used to calculate total room time, surgical time, prostate dissection time, and console time. Independent t-test or Pearson’s chi-square test were used to compare differences between groups.
RESULTS: Two RARP were aborted due to positive pelvic lymph node dissection (1 in each group). Of the remaining 89, 65 (73%) were performed EP and 24 (27%) TP. There was no statistical difference between groups with regard to age, Gleason biopsy or pathologic sum, pathologic stage, prostate volume, percentage of nerves spared, rate of bladder neck reconstruction, postoperative complication, or hospital stay. The median BMI was significantly higher in the TP group (p=0.014). There was no statistical difference in terms of port placement setup time. Prostate dissection time (p=0.002), console time (p=0.012), total surgical time (p=0.012) and total time of room occupancy (p=0.036) were significantly higher in the TP group.
No statistical difference in blood loss was observed. No transfusion was required in either group. Overall margin positivity was not statistically different (EP 7.7%, TP 16.7%; p =0.213). Positive margin rates in pT2 disease were statistically equivalent as well (2% EP, 0%TP). There were no intraoperative complication in either group. Two postoperative complications occurred in the EP group: an anastomotic disruption requiring robotic assisted re-exploration, and one early hydronephrosis that was managed with nephrostomy tube drainage and stenting. In the EP and TP groups, 89% and 91.7% of the patients were discharged on postoperative day 1. Reasons for readmission prior to scheduled follow up visit were: ileus (2), hematuria (1), urinary retention (2).
CONCLUSIONS: The differences observed between TP and EP likely reflect our selection bias, reserving TP for patients with higher BMI, which allows a better working angle in these patients. The higher surgical times in the TP group likely reflect surgical challenges in this population rather than the approach. Contrary to our assumption, EP setup times are equivalent to TP. The choice of the surgical approach remains ultimately dependent on the surgeon preference.